Treating uninsured immigrants after health care reform

The Affordable Care Act was intended to provide insurance for the uninsured – with one notable exception. Undocumented immigrants and lawfully present immigrants who’ve been here less than five years are excluded from health care reform. They are not eligible to purchase private insurance on state exchanges and they remain ineligible for Medicaid.

National Immigration Law Center Health Policy Attorney Sonal Ambegaokar says the decision to exclude those populations was purely political — since excluding them undermines the effectiveness of the reform.

“The goal of the first step was to provide affordable coverage for as many people as possible,” Ambegaokar said. “You want as many people in the insurance pool because you want to spread the risk. Excluding immigrants is counter-productive.”

As of 2010, there were about 38 million immigrants living in the United States. The Pew Hispanic Center estimates about 11.2 million of them are undocumented.

Non-citizens, both undocumented and lawfully present, are three times more likely then U.S.-born citizens to be uninsured, according to the Kaiser Family Foundation. They tend to work in jobs without employer sponsored health care. Their access to Medicaid and the Children’s Health Insurance Program (CHIP) is also limited. Altogether, they account for 20 percent of the uninsured.

The Congressional Budget Office estimates that 30 million Americans will remain uninsured two years after the Medicaid expansion and state health benefit exchanges are established in 2014.

Twenty-five percent of the remaining uninsured will not qualify for coverage because of immigration status, according to a recent report from the UC Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research.

Spreading the word

The report also found, however, that half of those still uninsured five years after the reforms take effect will actually qualify for the expanded Medi-Cal coverage or health benefit exchange subsidies, but will not enroll because of poor outreach. A large majority of the remaining uninsured will be Latino (66 percent), limited English proficient (60 percent) and/or residents of Southern California (62 percent).

Chad Silva, Policy Director for The Latino Coalition for a Healthy California, worries that the state doesn’t realize the resources and grassroots efforts it would take to reach these populations.

Partnerships with community-based organizations are fundamental for connecting to residents that are often labeled “hard to reach,” Silva said. Community health educators called promotoras are particularly important, providing both formal and informal networks of people educating their neighbors in Latino communities throughout the state.

Another key reason that people who qualify will remain uninsured is confusion about who is covered and who is not. In 2010, more than 6 million citizen children were living in a “mixed citizenship status” family, with at least one non-citizen parent. These families aren’t likely to apply for coverage for anyone in the family, Sonal Ambegaokar said, when they hear that non-citizens aren’t covered.

Community clinics can play an essential role in providing for these patients because they will be able to care for the newly insured as well as those who remain uninsured. The 10 clinics in the San Francisco Community Clinic Consortium (SFCCC) provide a medical home for the whole family, said John Gressman, President and CEO of SFCCC.

The SFCCC is developing an outreach plan with other clinics throughout the state to help their patients understand what the reforms will mean for them. They will also help clients enroll when the California health benefit exchange opens October 1, 2013.

Latinos also have the most to gain from the ACA, Silva said. According to recent estimates by the California Pan-Ethnic Health Network (CPEHN) more than two million Latinos will be newly eligible for Medi-Cal or insurance subsidies through the health benefit exchange. The fact that childless adults now qualify for Medi-Cal is also a boon for young Latinos.

Treating the uninsured after the ACA

SFCCC clinics expect 35 percent of their clients will qualify for new coverage, but Gressman is struggling to figure out how to pay for the care of the 25 percent of their patients who will remain uninsured. “We can’t use Medi-Cal or any federal dollars through the exchange,” Gressman said. “There are many conversations trying to figure out how we can finance this, but I don’t think anyone has solved this.”

One strategy is to try to reduce their costs and reorganize the way they provide care. The SFCCC clinics are changing to a team-based care model in order to be more efficient. “We want providers and staff members working to the top of their profession and delegating what others can do,” Gressman said.

Reducing health disparities is another way providers could reduce cost. SFCCC clinics are trying to do that by training providers in culturally competent health care.

Only 5 percent of doctors in California are Latinos while 38 percent of the population is Latino, Silva noted. Increasing the number of Spanish-speaking doctors is another way to improve cultural competency, currently about one quarter of Californian physicians speak Spanish according to a 2004 UCLA study.

Hospitals will still be required to provide emergency care to anyone who walks through their door. The ACA scales back “disproportionate care payments” to hospitals by about $18 billion from 2014 to 2020 on the premise that there will be less uninsured. But many hospitals are concerned they will continue to bear a disproportionate burden of providing for those who are still uninsured.

Undocumented immigrants avoid hospitals because of fear, Silva said. “They have to be walking dead before they go in,” Silva said. Community clinics have provided and will continue to provide an important safety net for uninsured Latinos, he said.

Luis Garcia, an immigrant from Mexico, can’t get insurance through the restaurant where he works, so he seeks care from Contra Costa County Community Health Clinics. His uninsured friends, he said, build up personal pharmacies by having relatives send them medications such as antibiotics that are cheaper and more readily available in their home countries. Some also frequent local herberias to seek natural remedies for what ails them.

Health advocates continue to lobby legislators to remove immigration status as a factor for qualifying for coverage in addition to their education and outreach efforts.

“The simpler the system the better the access will be,” Sonal Ambegaokar said.

The National Immigration Law Center is supporting the federal Health Equity and Accountability Act proposed in April by Hawaiian Senator Daniel Akaka. The legislation removes immigration qualifications to purchase insurance through the exchange and invests in community clinics and culturally competent care. The bill is currently in committee.

Any other changes in health care options for immigrants will likely have to be included in immigration reform, Silva said.

The most contentious issue at the moment is coverage for a group of hundreds of thousands of undocumented immigrants who came here as children, attended school and met other requirements to be allowed to stay in the country without threat of deportation.

The Obama administration ruled that they don’t fit the lawfully present definition of the ACA in August.

Silva advocates reevaluating what it means to be lawfully present.

“You certainly don’t want a large group of people going uninsured,” Silva said, “just in terms of public health.”